Sexual dysfunction can affect men of all ages, but it is more pronounced among older men. Sexual dysfunction is all about the lack of ability to enjoy normal sex. Male sexual dysfunction can include a wide ranging sexual health related problems including low libido, lack of sexual desire, erectile dysfunction, premature ejaculation, inability to get an erection or hold an erection for required period etc.,

A drop in sexual health is often linked with other physical problems. For instance

- Sexual problems such drop in libido, erection is a sign of cardiovascular or prostate cancer or other medical issues.

- Early ejaculation could indicate a nerve damage. While a drop in libido or erection may be the first sign of diabetes or hormonal imbalance.

- There is a strong link between mental health and sexual health.

- Mental health issues like depression, anxiety and other psychiatric illnesses can trigger sexual disorders. For both men and women, who are depressed can witness a decrease in libido

Though research suggests that sexual dysfunction is common among men and women in India, many people don’t want to express it because of lack of knowledge or because of embarrassment of expressing it to others, including doctors. In yesteryears, men with sexual dysfunction suffered silently, but now there is space to discuss about it and there are quite a lot of treatment options available to get a complete cure for men with such issues.

Before going any further, let us see what sexual dysfunction actually is?

Sexual Dysfunction

Sexual dysfunction is a problem that will prevent one from experiencing satisfaction during a sexual activity. This can happy for both men and women and can happen during any phase of the sexual response cycle.

Sexual response cycle

- Desire

- Excitement

- Plateau

- Orgasm

- Resolution

It is important to know that women don’t always go through these phases in order.

Who is most affected by sexual dysfunction?

Although sexual dysfunction can affect men and women of any age, it is more common in men over the age of 40 in India, often because of decline in overall health due to ageing.

What are the types of sexual dysfunction?

Sexual dysfunction generally is classified into four categories:

• Desire disorders: lack of sexual desire or interest in sex. No amount of exposure to erotic literature or porn videos will create a desire to try sex
• Arousal disorders: inability to become physically aroused or excited during sexual activity. When arousal doesn’t happen at the required time, it may be frustrating for the other partner
• Orgasm disorders: There could be a delay in achieving orgasm beyond required time or absence of orgasm (climax) at all.
• Pain disorders: People with this disorder will experience pain during intercourse. And stigma associated with pain will prevent them from indulging in normal sex.

What are the common symptoms of sexual dysfunction in Male?

- Inability to achieve or maintain an erection (hard penis) suitable for intercourse.

- Absent or delayed ejaculation despite enough sexual stimulation (retarded ejaculation).

- Inability to control the timing of ejaculation (early, or premature, ejaculation).

Sexual Dysfunctions in Male

- Hypoactive sexual desire/ Hyperactive sexual Desire

- Inhibited excitement/ Erectile Dysfunction/ Impotence

 - Orgasmic dysfunction

Early Orgasmic Response

Delayed Orgasmic Response

Incomplete Orgasmic Response

Absent Orgasmic Response

 - Dyspareunia (Pain during sex)

Dyspareunia is the term for recurring pain in the genital area or within the pelvis during sexual intercourse. The pain can be sharp or intense. Persistent or recurrent genital pain that occurs just before, during or after intercourse. Painful intercourse can have causes including inadequate lubrication, rough sex, trauma or negative feelings about a partner.

How does sexual dysfunction affect men?

The most common problems men face with sexual dysfunction are lack of control over ejaculation, getting and keeping an erection for desired period, and reduced sexual desire.

Ejaculation disorders

Problems with ejaculation are:

• Premature ejaculation (PE): Ejaculation that occurs before or too soon leading to an unsatisfied penetration experience for the partner.
• Inhibited or delayed ejaculation: Ejaculation does not happen or takes a very long time leading to exhaustion and frustration to the partner.
• Retrograde ejaculation: At orgasm, the ejaculate is forced back into the bladder rather than through the end of the penis. This again will leave both partners dissatisfied as it is kind of an unnatural process.

Though performance anxiety is one of the primary reasons identified for premature ejaculation, some of the other reasons include:

• Stress.
• Temporary depression
• History of sexual repression
• Low self-confidence.
• Lack of communication or unresolved conflict with partner

Studies suggest that the breakdown of serotonin (a natural chemical that affects the mood) may play a role in PE. Certain drugs, including some antidepressants, may affect ejaculation, as can nerve damage to the back or spinal cord.

Physical causes for inhibited or delayed ejaculation may include chronic (long-term) health problems, medication side effects, alcohol abuse, or surgeries. The problem can also be caused by psychological factors such as depression, anxiety, stress or relationship problems.

Retrograde ejaculation is most common in males with diabetes who suffer from diabetic nerve damage. Problems with the nerves in the bladder and the bladder neck force the ejaculate to flow backward. In other men, retrograde ejaculation may be a side effect of some medications, or happen after an operation on the bladder neck or prostate.

Erectile dysfunction (ED)

Erectile dysfunction (ED) is the inability to get and keep an erection for sexual intercourse. ED is quite common, with studies showing that about one half of American men over age 40 are affected. Causes of ED include:

• Diseases affecting blood flow such as hardening of the arteries.
• Nerve disorders.
• Stress, relationship conflicts, depression and performance anxiety.
• Injury to the penis.
• Chronic illness such as diabetes and high blood pressure.
• Unhealthy habits like smoking, drinking too much alcohol, overeating and lack of exercise.

Low libido (reduced sexual desire)

Low libido means your desire or interest in sex has decreased. The condition is often linked with low levels of the male hormone testosterone. Testosterone maintains sex drive, sperm production, muscle, hair and bone. Low testosterone can affect your body and mood.

Reduced sexual desire may also be caused by depression, anxiety or relationship difficulties. Diabetes, high blood pressure, and certain medications like antidepressants may also contribute to a low libido.

What causes sexual dysfunction?

There are two major factors that lead to the sexual dysfunction in male.

Physical causes

Psychological causes

Let us examine both causes in detail.

Physical Causes

The following are identified as some of the common medical conditions that lead to sexual dysfunction.

- Low testosterone levels

- Diabetes

- High cholesterol

- High blood pressure

- Heart and vascular diseases

- Obesity

- Neurological disorders

- Hormonal imbalances

- Kidney failure or liver failure

- Smoking

- Alcoholism and drug addiction

- Stroke or nerve damage due to chronic diabetes or surgery

- Side effects of some medications such as antidepressant drugs

- Metabolic syndrome — a condition involving increased blood pressure, high insulin levels, body fat around the waist and high cholesterol

- Sleep disorders

- Parkinson's disease

- Treatments for prostate cancer or enlarged prostate

- Surgeries or injuries that affect the pelvic area or spinal cord

- Certain medications (both prescribed and over-the-counter)

What medications can cause sexual dysfunction?

Through research it is understood that certain prescription medications and few over-the-counter drugs can impact sexual performance to a great extent. Some medicines are known to affect libido while others can affect the arousal levels and / or ability to achieve orgasm. When an individual is taking several medicines for chronic illnesses, then the risk of sexual side effects is increases manifold.

Sexual side effects have been reported with the following medications:

Non-prescription medicines

Some over-the-counter antihistamines and decongestants can cause erectile dysfunction or problems with ejaculation.

Antidepressants

• Tricyclic antidepressants, including amitriptyline (Elavil), doxepin (Sinequan), imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor)
• Monoamine oxidase inhibitors (MAOIs), including phenelzine (Nardil) and tranylcypromine (Parnate)
• Antipsychotic medications, including thioridazine (Mellaril), thiothixene (Navane), and haloperidol (Haldol)
• Anti-mania medications such as lithium carbonate (Eskalith, Lithobid)
• Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).

The following medications may cause erectile dysfunction:

Anti-hypertensive medications (used to treat high blood pressure)

• Diuretics, including spironolactone (Aldactone) and the thiazides (Diuril, Naturetin, and others)
• Centrally acting agents, including methyldopa (Aldomet) and reserpine (Serpasil, Raudixin)
• a-Adrenergic blockers, including prazosin (Minipress) and terazosin (Hytrin)
• b-adrenergic (beta) blockers, including propranolol (Inderal) and metoprolol (Lopressor)

The following medications may decrease sexual desire:

Hormones

• Leuprolide (Lupron)
• Goserelin (Zoladex)

Psychological Concers

Some of the common psychological concerns that lead to sexual dysfunction include

- Work-related stress

- Anxiety and concern about sexual performance

- Marital or relationship problems

- Depression

- Feelings of guilt

- Concerns about body image

- Effects of traumatic past sexual experiences

Psychological Causes

There are two psychological causes identified to create sexual dysfunction

Immediate

Remote (Deeper)

Immediate causes

These are identified as causes that are on the surface of the psychological issues, it is more to do with their perceptions and beliefs about sexuality.

Avoidance of / failure to engage in a normal sexual behaviour which is exciting and stimulating due to pre-conceived notion

Performance anxieties:Creating strong intellectual defenses against erotic pleasure. Strong mindset against sexual pleasure deeming it as imaginary or unreal or evil

Fear of failure (exacerbated by pressure to perform or due to previous sexual experiences)

Fear of rejection (leading to concern about pleasing the partner or due to low self-esteem)

Failure to communicate openly and without guilt with the partner about sexual preferences.

Remaining insensitive towards partner’s genuine feelings, wishes and responses resulting in unsatisfying sexual co-operation from partner leading to frustration and aversion to sex.

Remote causes

These are identified as causes that have a deeper impact on the sexual dysfunction of a male. These are psychological causes that are deeply ingrained in the mind of the concerned. It has lot to do with fundamental belief system, upbringing, socio-cultural and other factors that play a vital role in the sexual health of the individual.

When there is an Intra-psychic conflict between the desire for sexual enjoyment and unconscious fear of sexual pleasure can lead to sexual dysfunction. The reasons could be

Sexual sources – These are some of the conflicts that remain deep rooted in the mind, which are formed and shaped due to socio-cultural factors and constrictive upbringing in which sex is taught as being evil or impure or immoral act. This internal conflict can come into play during physical sex leading to sexual dysfunction.

Non-sexual sources – These are more to do with interpersonal relationship issues such as inability to develop trust, lack of character, strong ego and not able to forge strong, secure and intimate relationship can lead to sexual dysfunction when one happens to have physical sex.The other aspects of non-sexual sources include:

Partner rejection

Lack of communication

Marital discord

Conditioning and reinforcement – Traumatic early sexual experiences can have a severe negative conditioning towards sex leading to sexual dysfunction. The disturbing experiences of the past will outweigh the pleasure that is part of the normal sex leading to aversion towards sex.

How sexual dysfunction is diagnosed?

In most cases, one partner will recognize that there’s something that is affecting their sexual enjoyment severely leading to a visit to the physician.

Your physician may begin the diagnosis process with a physical exam that may include:

• Blood tests to check your testosterone levels, blood sugar (for diabetes) and cholesterol
• Blood pressure check
• Rectal exam to check the condition of the prostate
• Examination of your penis and testicles
• Other tests to see if you have problems with blood flow to the penis.

Your doctor may also ask questions about your symptoms and your medical and sexual history. Though these questions may seem very personal, do not be embarrassed. It is important to answer honestly so the best treatment can be recommended. You may be sent to a different type of doctor (urologist, endocrinologist or sex therapist, for example) who can help you.

The physician will begin the diagnosis with a complete history of sexual behavior, check the obvious physical symptoms. Then psychological factors such as attitude towards sex, anxiety, fear, past sexual trauma / physical abuse, relationship issues, alcoholism or drug intake, medications are carefully evaluated to understand the problem at the psychological level.

Based on the complete study of physical and psychological aspects of the sexual health, the physician would recommend the right treatment based on the age, physical strength, current medication etc.,

MANAGEMENT AND TREATMENT

Don’t be ashamed to ask for help. Once correctly diagnosed, there is plenty you can do to improve your life in the bedroom.

How is sexual dysfunction treated?

Most types of sexual dysfunction can be addressed by treating the underlying physical or psychological problems. Other treatment strategies include:

Medication: Required medicines based on your physical or psychological needs will be given to get your body in normal healthy condition so that your sexual health would be improved.

Mechanical aids: Aids such as vacuum devices and penile implants may help men with erectile dysfunction (the inability to achieve or maintain an erection). A vacuum device is also suggested for use in women. Dilators may help women who experience narrowing of the vagina. Devices like vibrators can be helpful to help improve sexual enjoyment and climax.

Sex therapy: Sex therapists can people experiencing sexual problems that can’t be addressed by their primary clinician. Therapists are often good marital counselors, as well. They will help men and women overcome psychological reasons that are inhibiting them from enjoying quality sex.

Behavioral treatments: These involve various techniques, including insights into harmful behaviors in the relationship, or techniques such as self-stimulation for treatment of problems with arousal and/or orgasm.

Psychotherapy: This is done for those who had traumatic sexual experience early in their life. The trained counselor can help such patients address sexual trauma from the past, feelings of anxiety, fear, guilt and poor body image leading to a happy approach towards sex.

Education and communication: Education about sex and sexual behaviors and responses may help you overcome anxieties about sexual function. Open dialogue with your partner about your needs and concerns also helps overcome many barriers to a healthy sex life.

Can sexual dysfunction be cured?

The success of treatment for sexual dysfunction depends on the underlying cause of the problem. When the problem is identified and the person is young, then dysfunction can be treated or reversed. Please know that mild dysfunction that's related to stress, fear or anxiety often can be successfully treated with counseling, education and improved communication between partners. But severe ones requiring both physical and psychological treatments may take a long time to get cured. Age can also play a crucial factor in determining the duration of the treatment.

Can male sexual dysfunction be prevented?

While male sexual dysfunction cannot be prevented, dealing with the causes of the dysfunction can help you better understand and cope with the problem when it happens.

Erectile dysfunction is a multidimensional but common male sexual dysfunction that involves an alteration in any of the components of the erectile response, including organic, relational and psychological. Roles for nonendocrine (neurogenic, vasculogenic and iatrogenic) and endocrine pathways have been proposed.

Owing to its strong association with metabolic syndrome and cardiovascular disease, cardiac assessment may be warranted in men with symptoms of erectile dysfunction. Minimally invasive interventions to relieve the symptoms of erectile dysfunction include lifestyle modifications, oral drugs, injected vasodilator agents and vacuum erection devices. Surgical therapies are reserved for the subset of patients who have contraindications to these nonsurgical interventions, those who experience adverse effects from (or are refractory to) medical therapy and those who also have penile fibrosis or penile vascular insufficiency.

Erectile dysfunction can have deleterious effects on a man’s quality of life; most patients have symptoms of depression and anxiety related to sexual performance. These symptoms, in turn, affect his partner’s sexual experience and the couple’s quality of life.

This Primer highlights numerous aspects of erectile dysfunction, summarizes new treatment targets and ongoing preclinical studies that evaluate new pharmacotherapies, and covers the topic of regenerative medicine, which represents the future of sexual medicine.

Lifestyle factors and diabetes

Alcohol and smoking habits have consistently been shown to affect erectile function. Evidence from observational studies suggests a positive dose–response association between quantity and duration of smoking and the risk of erectile dysfunction. 

In addition, diets that are low in whole-grain foods, legumes, vegetables and fruits, and high in red meat, full-fat dairy products, and sugary foods and beverages are all associated with an increased risk of erectile dysfunction.

Finally, meta-analysis of available evidence demonstrates that moderate and more frequent physical activity are associated with reduced risk of erectile dysfunction. Sexual health is impaired by type 1 and type 2 diabetes and even by a pre-diabetic status.

Cardiovascular disease

Recommendations for the management of erectile dysfunction and cardiovascular disease indicate that incident erectile dysfunction has a similar, or even greater, predictive value for cardiovascular disease than traditional risk factors such as diabetes, hypertension, dyslipidaemia or smoking.

Psychogenic and relationship factors

Although considered less often, the quality of a relationship represents an essential determinant of successful sexual activity. In fact, any sexual dysfunction in one member of the couple will affect the couple as a whole, causing distress, partner issues and further exacerbation of the original sexual problem. Hence, the physical relationship between partners should be considered not only as enjoyable, but also as a strategy for improving overall health and life expectancy.

Lifestyle modification

Lifestyle modifications can have a major role in managing erectile dysfunction, especially in the younger patient.

- It is recommended that adults should do 30 minutes of moderate-intensity aerobic activity most days of the week.

- Weight loss in obese men, and switching from an unhealthy diet to a healthy diet, plus exercise, has been shown to improve erectile dysfunction outcomes

- Smoking has been shown to have a direct relationship with erectile dysfunction, and a dose response relationship has been suggested because men have increased erectile difficulties with greater numbers of packets of cigarettes smoked or more years of smoking.

- Mild alcohol consumption might improve erectile function by reducing anxiety; however, chronic use or alcohol abuse can have lasting effects on the liver, leading to low levels of testosterone which can contribute to erectile dysfunction

To help maintain good sexual function you should follow the same program that is recommended to maintain cardiovascular health.

- Follow your doctor’s treatment plan for any of your medical/health conditions.

- Limit your alcohol intake

- Quit smoking completely. Never restart

- Eat a heart healthy diet – Choose your own diet, but the Mediterranean Diet is the highly recommended diet that is known the keep the heart stronger

- Get regular aerobic and weight building exercise.

- Get treatment if needed for any emotional or psychological problems such as stress, depression and anxiety.

- Communicate better and more often with your partner.

- If you are taking medications that are known to cause sexual dysfunction, request your doctor to provide another drug (is possible) that doesn't have a side effect of sexual dysfunction. Never take any non-prescribed or OTT drugs without your physician’s knowledge.  

Conclusion

Being in a satisfying and steady relationship, healthy diet, regular physical exercises and a positive attitude towards life and sex can go a long way in preventing sexual dysfunction.

Sex is an elixir, let us enjoy it the most.